PlattCollege

Nursing Program

Student’s Name: ___Mbaabe Jacqueline______Date of Care: ___10/31/2012______

Client Initials: __sb______Room #:____04______Admission Date: _10/30/12______Age:_____25______Sex: __female______Ht:_5’6’’_____Wt:___172lbs______

Marital Status: S M W D Role in family: ____single______Occupation: ______

Education: ____high school diploma______Family Members: _mom, boyfriend, sister.______Cultural background: ___cau[v1]______

Religious affiliation: __christian______Spiritual practices: ___loves to meditate ______

Interests / hobbies: ______reading, walking the dogs. ______

Lifestyle habits: Smoking: Y or N Amount: ___no______Recreational drug use: ______no______Frequency: ______

Allergies (drug, food, other): _____PCN[cj2]______Diet Ordered:__regular______

Pertinent Medical History: ____c-section, depression[cj3], ______Developmental Needs/Tasks __according to Erickson she is on intimacy versus isolation, she falls under intimacy because right now she is happy she is has a fiancée and they just had their baby and are really excited about it. On Maslow she falls on safety because she has her physiologic needs met like for food, air, and sleep[cj4]. She does not currently have a job which means her safety needs are not yet met. ______

AdmittingDiagnosis: ______cesarean delivery. ______

Secondary Diagnosis: ______

Surgery Type/Date (if any): _c-section 10/30/2012[v5]______

Admitting Diagnosis/Etiology (describe patient condition, related to diagnosis, pathophysiology, and sign/symptoms): ______Cesarean delivery is defined as the delivery of a fetus through surgical incisions made through the abdominal wall[cj6]. A Cesarean section, also known as a C-section, is used to deliver a baby under certain circumstances that prohibit vaginal birth.Reasons you might need an unplanned C-section include, if labor is slow or stops completely. The baby shows signs of distress, such as a very fast or slowhear rate an, example will be the baby I took care of who had non reassuring fetal heart tone which led to cesarean birth. A problem with the placenta or umbilical cord puts the baby at risk. The baby is too big to be delivered vaginally.When doctors know about a problem ahead of time, he might schedule a C-section. Reasons you might have a planned C-section include, the baby is not in a head-down position, you are close to yourdate, and you have a problem such asheart diseasethat could be made worse by labor stress. You have an infection that you could pass to the baby during a vaginal[cj7] birth or if you are carrying more than one baby. .______

Medications/IV Fluids (Complete the following table)

Drug Name / Dose / Was drug given / time / Frequency / Route / Drug Classification / Reason Ordered / Actual evaluation / client response
Remeron / 15mg / No / QHS / Po / Antidepressant / Depression / none
Oxycodone / 5mg / Yes / Q 4 hours PRN / Po / Narcotic analgesic / ABD pain / Pain level decrease[cj8].
Colace / 100mg / No / Q 4 hours PRN / Po / laxative[cj9] / constipation / No constipation[cj10]
IBU / 800mg / No / Q 4 hours PRN / Po / NSAID / pain / Pain level decrease

Laboratory Tests(Complete the following table)

Test Name / Client Results: Give level and indicate high [H] or low [L] or normal [N] / Range of Normal / Significance of Client Result
Hematocrit / 37.3% / 37- 47% / Normal on low side[cj11].
Hemoglobin / 13 / 12-16g/dl / Within normal range
RBC / 4.2-5.4 million / 4.2-5.4 million / Within normal range
WBC / 8,500mm / 4.500-11,000/mm / Within normal range
Platelet / 240,000mm / 150,000-400,000/mm / Within normal range

Diagnostic Test, Results and Significance: (attach additional pages as needed)

______none______

Problem
Pain 8 on a 0-10 scale
Abdominal Incision
anxiety / Assessment Data (5)
25 years old gravida 1, Para 1,
Alert oriented to person place, date and time.
B/P 102/58,
Pulse 78
Temp. 97.8
Pain 8 on 0-10 scale
Scant amount of lochia.
Abdominal incision to lower abdomen due to c-section, dry and intact.
Report pain 8 on a 0-10 scale[cj12]. / Nursing Diagnosis
Acute pain related to c-section incision AEB pt stating she has a pain level of 8 on a 0-10 scale and guarding behaviors. / Intervention Implemented [I] Not implemented [NI]
Assess duration and type of pain and what intensify the pain. (I)
Administer pain meds as ordered. (I)
Give the pt abdominal pillow and tell the pt to secure the incision site when coughing or moving. (I) / Rationale
To obtain information and plan appropriate nursing intervention. (Sparks and Taylor, page[cj13]. 514)
To provide pain relief. (Sparks and Taylor, page. 514)
To provide support for the abdominal muscle. (Sparks and Taylor, page. 514) / Outcomes Actual [A] or Proposed [P]
Pt identifies characteristics of pain and factors that intensify the pain. (A)
Pt took prescribed meds and verbalizes relief. (A)
Pt expresses comfort and relief from using ABD pillow. (I) / Short-term Goal
Within one hour of intervention pt will report a decreased level of pain lower than 2 on a 0-10 pain scale[cj14]. / Long-term Goal
Pt will be free from pain by Discharge[cj15]. teaching done and client verbalizes back to nurse to,
To always take pain medication as ordered when in pain.
To notify physician if current med is not working or if she has bad side effect[cj16].
Also referred client to pain center[cj17] for long term treatment of pain if pain progresses.
Problem
Abdominal wound
Altered primary defense.
Pain 8 on scale 0-10.
anxiety / Assessment Data (5)
25 years old gravida 1, Para 1,
Alert oriented to person place, date and time.
B/P 102/58,
Pulse 78
Temp. 97.8
Pain 8 on 0-10 scale
Scant amount of lochia.
Abdominal incision to lower abdomen due to c-section, dry and intact.
Report pain 8 on a 0-10 scale / Nursing Diagnosis
Risk for infection[cj18] related altered primary[cj19] defenses AEB abdominal incision. / Intervention Implemented [I] Not implemented
[NI]
Wash your hands thoroughly before and after taking care of client. (I)
Assess pt for generalized S/S of infections like increase temperature, chills, fatigue every shift. Also inspect incision site for purulent drainage and odor every shift. (I)
Provide appropriate wound care using sterile technique as ordered. (I) / Rationale
Hands washing are the single best way to avoid spreading pathogens. . (Sparks and Taylor, page. 489)
Prompt detection of infection helps minimize complications. . (Sparks and Taylor, page. 489)
Proper wound care facilitates wound healing and reduces the number of pathogens that enters a wound, which reduce the risk for wound becoming infected. . (Sparks and Taylor, page. 490) / Outcomes Actual [A] or Proposed [P]
Maintain good patient hygiene. (A)
Pt vital signs remain within normal limit. Temperature 97-99.0 degrees. (A)
Pt remains free from infection. (A) / Short-term Goal
Within 24 hours with intervention pt will maintain normal vital sign and have zero s/s of infection[cj20]. / Long-term Goal
Pt will be free from infection.
Discharge teaching done and pt verbalizes understanding back to nurse,
To always wash hands before and after changing incision dressing.
To monitor for s/s of infection and immediately notify physician if temperature increases, if wound site has foul drainage or odor.
Teaching done on not wearing tight clothing especially around the incision sit and client verbalizes understanding to always wear loose clothing.
Problem / Assessment Data (5) / Nursing Diagnosis / Intervention Implemented [I] Not implemented [NI] / Rationale / Outcomes Actual [A] or Proposed [P] / Short-term Goal / Long-term Goal
Problem / Assessment Data (5) / Nursing Diagnosis / Intervention Implemented [I] Not implemented [NI] / Rationale / Outcomes Actual [A] or Proposed [P] / Short-term Goal / Long-term Goal

[v1]Need more explanation

[cj2]What is the reaction?

[cj3]How many previous c-sections?

How long has pt been depressed? Has it been managed well during pregnancy?

[cj4]Re-think this! You can be safe and jobless.

[v5]Very good

[cj6]Pg. 525, 526, 527 in text. Are these your words? Why didn’t you cite the source (to avoid plagiarism)

[cj7]Why did this particular pt have a c/s?????? That is what your etiology is suppose to be; individualize, do not generalized.

[cj8]What pain level? What scale?

[cj9]NOT a laxative (stool softner)

[cj10]Is the stool soft? Has pt had a BM

[cj11]So what is significant about that.

[cj12]You did not describe the pain at all. This is not okay.

[cj13]Page ????

[cj14]Your whole care plan focuses on pain and yet you did not re-evaluate the pain level?????????????

[cj15]Absolutely NOT realistic

[cj16]Notify physician if pain is not well controlled or has s/s of medication reaction. SPEAK IN PROFESSIONAL NURSING LANGUAGE.

[cj17]What? This is not going to be a life- long pain management issue. This is not appropriate.

[cj18]Low chance of infection. C/s are prophylatically treated with IV antibiotics and rarely experience incision site infections.

[cj19]This patient has a history of depression. Risk for Postpartum depression is a much higher priority.

[cj20]Sign of infection will not even show up in that time-frame !!!!!!!!!!!!!!!!!!!!!! NOT realistic.